Provider Demographics
NPI:1235180670
Name:BRODERICK, JOHN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:480 FLOYD RD
Practice Address - Street 2:SUITE A
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1518
Practice Address - Country:US
Practice Address - Phone:864-582-2188
Practice Address - Fax:864-582-2117
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16584207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC165840Medicaid
SC200032060OtherRR MEDICARE
SC576007863084OtherBCBS OF SC
SCP00797721OtherRR MEDICARE
SC4460681OtherCIGNA
SC5391725OtherAETNA
SC5391725OtherAETNA
SCG71282Medicare UPIN
SCP00797721OtherRR MEDICARE
SCG712827951Medicare PIN
SCSC07903365Medicare PIN